Upper GI Bleeds

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75% of all gastrointestinal bleeds are classified as upper GI bleeds. An upper GI bleed is defined as a bleeding taking place proximal to the ligament of Treitz, a suspensory ligament where the fourth portion of the duodenum transitions to the jejunum.

Etiology

·      Above the GE junction

o   Epistaxis

o   Esophageal varices (10~30%)

o   Esophagitis

o   Esophageal cancer

o   Mallory-Weiss tear (10%)

·      Stomach

o   Gastric ulcer (20%)

o   Gastritis (20%)

o   Gastric cancer

o   Gastric antral vascular ectasia (rare condition where small blood vessels are dilated around the antrum of the stomach—resulting in “watermelon stomach”; associated with cirrhosis, chronic kidney failure, and collagen vascular disease.)

o   Dieulafoy’s lesion (very rare where a large, tortuous arteriole in the submucosa of the stomach erodes and bleeds)

·      Duodenum

o   Ulcer in bulb (25%)

o   Aortoenteric fistula: rare and lethal; usually only if previous aortic graft has been done

·      Coagulopathy (drugs, renal disease, liver disease)

·      Vascular malformation

Clinical features includes patient noticing blood is coming out his/her GIT. This can be in a variety of forms. In order of decreasing severity of the bleed: hematochezia (blood—usually fresh—passed through anus, can be along with or mixed in stools), hematemesis (vomiting up blood—usually fresh), coffee ground emesis (vomiting old blood), melena (old blood passed through anus), and occult blood in stool.

ALWAYS ask about NSAID, aspirin, or anticoagulant drug use!

Initial management

1.     Resuscitate patient with 2 large bore IVs, IV fluids, monitor vital signs

2.     Send blood for CBC, cross and type, platelets, prothrombin time (PT), partial thromboplastin time (PTT), electrolytes, BUN, creatinine, and liver function tests.

3.     Keep the patient fasting

4.     NGT can be considered to determine upper vs. lower GIT bleeding

5.     Endoscopy is done to establish bleeding site and treat lesion

·      For bleeding peptic ulcers, the most commonly used method of controlling bleeding is injection of epinephrine around bleeding point and thermal hemostasis via bipolar electrocoagulation or heater probe. Less often thermal hemostasis may be used alone. Injection alone is not recommended

·      Endoclips

·      Hemospray—mineral blend powder specifically used for endoscopic hemostasis. It absorbs water to form a cohesive and adhesive mechanic barrier around the bleeding site.

6.     Administer PPI (IV) to decrease the risk of rebleeding if endoscopic predictors of rebleeding are seen

·      PPI is given to stable the clot, not to accelerate ulcer healing

·      If given before endoscopy, it decreases need for endoscopic therapeutic intervention

7.     For variceal bleeds, administer octreotide 50 micrograms loading dose followed by constant infusion of 50 micrograms/hour

8.     Consider IV erythromycin or metoclopramide to accelerate gastric emptying prior to gastroscopy to remove clots from stomach.

Review—PT vs. PTT

Both PT and PTT are tests done to assess whether the patient has a coagulation problem. PTT stands for partial thromboplastin time (sometimes also called activated partial thromboplastin time APTT) and measures the function of the intrinsic coagulation pathway; PT stands for prothrombin time and measures the function of the extrinsic coagulation pathway. The way to remember the difference is this: the 2 T are no longer together à they are “exes” à PT measures extrinsic pathway. Why are they not together anymore? Because one of them got the “7 year itch” à PT/extrinsic pathways deals with factor VII while PTT deals with all other factors.

Prognosis

·      80% stop spontaneously

·      Peptic ulcer rebleeding occurs in 25% of patients. If there is no rebleeding, mortality is low 2%; however, it rises to 10% if rebleeding occurs.

·      Endoscopic predictors of rebleeding includes: spurt or ooze, visible vessel, or fibrin clot

·      H2-antagonists have little impact on rebleeding rates and need for surgery

·      Esophageal varices have a high rebleeding rate (55%) and mortality (29%)

·      Patients can be sent home if:

o   They are clinically stable

o   Bleeding was minor

o   No comorbidities

o   Endoscopy shows clean ulcer with no predictors of rebleeding

Constipation

Today we are going to discuss a very common condition that I’m sure most of us have experienced at one point in our lives; so it’s going to be a topic that is very relatable. And it’s about POO! So it will relatable and awkward as well! Without further ado, let’s dive into the enemy of mankind and what many people view as the bane of their existence: constipation!

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And on to today's topic:

Constipation is the passage of infrequent or hard stools with straining. “Infrequent” is defined as < 3 times/week, and “hard” is defined as stools with water content < 50ml. As mentioned previously, it is a very common condition, increasing in prevalence with age and affecting more females than males. Having said that, constipation is less common in Africa and India, where stool weight is 3~4 times greater than Western countries.

Constipation can have many different causes. The most common one is idiopathic, attributed to colon dysmotility—but this is very difficult to quantify. Other organic causes include medication side effects (narcotics, antidepressants), intestinal obstruction, left sided colon cancer (consider in older populations), and fecal impaction. Metabolic causes such as diabetes mellitus, hypothyroidism, hypercalcemia, hypokalemia, and uremia can also result in constipation, as do neurological causes such as intestinal pseudo-obstruction, Parkinson’s disease, and multiple sclerosis. Some collagen vascular diseases (e.g. scleroderma) can cause constipation; and painful anal conditions (e.g. fissures) can definitely cause constipation too.

Mnemonic for causes of constipation: DOPED

Drugs

Obstruction

Pain

Endocrine dysfunction

Depression

Clinical presentation of constipation can be very similar to that of IBS. The stool is firm, difficult to expel, and passed with straining. There is associated abdominal pain that is relieved by flatulence and defecation. Other symptoms include tenesmus, abdominal distention, overflow diarrhea, and infrequent bowel movements.

If constipation is the only symptoms, the underlying disease can be very difficult to find; the only test recommended by American Gastroenterology Association (2013) would be CBC—to exclude any sinister, systemic conditions. However, TSH, calcium, and glucose levels can also be helpful, as is an abdominal X-ray. If the constipation is associated with rectal bleeding, weight loss, or anemia, visualization of the colon through colonoscopy or CT colonography would be indicated.

For constipation that is refractory to treatment, colon transit time can be measured by having the patient ingest radio-opaque markers then taking a series of abdominal X-rays. The normal time is around 70 hours. If the colon transit time test result is indeed normal, then the patient has a misperception of normal defecation (IBS). If the result is prolonged throughout, the patient has “colonic inertia” (infrequent bowel movements with gas/bloating, often occurring in youth). If the result shows outlet obstruction, it could be that the patient is unable to coordinate pelvic muscles to empty rectum, causing straining. This tends to occur in old age, and often stool will be found in rectum on digital exam.

Treatment (in order of increasing potency):

·      Dietary fiber

o   Useful in mild/moderate constipation

o   Aim for 30g daily, increasing dosage slowly

·      Surface-acting agents (to soften and lubricate stools)

o   Docusate salts

o   Mineral oils

·      Osmotic agents (effective in 2~3 days)

o   Lactulose

o   Sorbitol

o   Magnesium salts

o   Lactitol

o   Polyethylene glycol 3350

·      Cathartics/stimulants (effective in 24 hours)

o   Castor oil

o   Senna (avoid prolonged use to prevent melanosis coli)

o   Bisacodyl

·      Enemas and suppositories

o   Saline

o   Phosphate

o   Glycerin

o   Bisacodyl

·      Prokinetic agents

o   Prucalopride

·      Linaclotide—increases water secretion into the intestinal lumen.

Irritable Bowel Syndrom

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On to today's topic:

Irritable bowel syndrome is a diagnosis that is being handed out much more readily these days, and it is often featured/referenced in pop culture (usually in a comical way). But what is IBS exactly? It is much more real and severe than you think! So this week let’s find out more about this mysterious disease.

To start off, irritable bowel syndrome is a form of functional bowel disease (which means that although the organs seem normal, there are still signs that something is wrong). Irritable bowel is more than a label for unexplained GIT symptoms because although many investigations come back normal (indicating normal anatomy), there is often abnormal motility. It can also be associated with abnormal perception of intestinal activity as well; however while psychological stress may increase IBS symptoms, it probably does not cause IBS. IBS affects 20% of North Americans, more so females than males; and the onset of symptoms usually start in young adulthood.

There are four types of IBS: IBS with diarrhea, IBS with constipation, IBS with mixed type (involving both diarrhea and constipation), and IBS un-typed (insufficient abnormality in stool to fit into any one category).

IBS is essentially a syndrome of pain.

Things that are definitely NOT IBS:

1.     Pain NOT relieved by passing of stools

2.     Patient waking up at night due to pain

3.     Blood in the stools

4.     White blood cells in stools

5.     Fever

6.     Weight loss

7.     Anemia

8.     Abnormal gross findings on flexible sigmoidoscopy

Physical examination should be normal in IBS patients. If history is consistent with Rome III criteria with no alarm features (see list above), and no family history of IBS or colorectal cancer, then limited investigations are required. The investigations aim to rule out diseases which mimic IBS (see list below), especially coeliac disease and inflammatory bowel disease; investigations can be limited to CBC, inflammatory markers (ESR, CRP), and coeliac serology. If available, fecal calprotectin is likely more reliable test to rule out inflammatory bowel disease. TSH and stool cultures can be considered based on clinical circumstances. Consider colonoscopy if alarm features present, family history of IBD, or age > 50 years.

IBS mimickers:

1.     Enteric infections e.g. Giardia

2.     Lactose intolerance (watch for osmotic ion gap)

3.     Crohn’s disease

4.     Coeliac disease

5.     Drug-induced (e.g. laxative)

6.     Diet-induced (e.g. caffeine)

Treatment includes reassurance, explanation, and support for the patient; aim for realistic goals. Lifestyle changes include relaxation therapy, biofeedback, hypnosis, stress reduction, and exercise. A diet that is low in fat and high in fiber can help with symptoms such as pain, bloating, and irregular bowel movements—of these, pain is most difficult to control. No therapeutic agent is consistently effective for IBS; so all medications are to treat symptoms as necessary.

Symptom-guided treatment

·      Pain predominant

o   Antispasmodic medication (such as hyoscine, pinaverium, trimebutine) before meals (low evidence).

o   Tricyclic antidepressants, selective serotonin reuptake inhibitors (moderate evidence).

·      IBS with diarrhea

o   Loperamide (Imodium)

o   Diphenoxylate (Lomotil)

o   Cholestyramine

·      IBS with constipation

o   Linaclotide

o   Osmotic or other laxative

80% of patients will improve over time, despite intermittent episodes of symptoms. Most will have normal life expectancy.